NR224 Exam 1 Actual Exam Style V1 | NR
224 Fundamentals - Skills | Chamberlain
1. When a patient’s hands are visibly soiled with blood or body fluids, which hand hygiene
method should the nurse use?
A. Washing with soap and water
B. Alcohol-based hand rub
C. Wiping with a dry paper towel
D. Rinsing with warm water only
Answer: A
Rationale: The CDC and WHO guidelines state that soap and water must be used when
hands are visibly soiled. Alcohol-based rubs are ineffective against physical debris and
certain spores like C. difficile. Proper technique requires at least 20 seconds of vigorous
scrubbing to mechanically remove microorganisms.
2. In which order should the nurse apply personal protective equipment (PPE) before entering
an isolation room?
A. Gown, Mask, Goggles, Gloves
B. Gloves, Gown, Mask, Goggles
C. Mask, Goggles, Gloves, Gown
,D. Goggles, Mask, Gown, Gloves
Answer: A
Rationale: The correct sequence for donning PPE is to start with the gown to protect
clothing, followed by the mask or respirator. Next, goggles or a face shield are applied to
protect the eyes and face. Finally, gloves are put on and pulled over the cuffs of the gown to
ensure complete coverage.
3. The nurse is preparing to take a patient’s blood pressure. Which action will result in an
incorrectly low blood pressure reading?
A. The arm is positioned above heart level
B. Cuff wrapped too loosely
C. Using a cuff that is too narrow
D. Deflating the cuff too slowly
Answer: A
Rationale: If the arm is positioned above the level of the heart, gravity helps blood flow
and results in a false low reading. Conversely, a cuff that is too narrow or wrapped too
loosely would typically cause a false high reading. Proper positioning requires the arm to
be supported at the midpoint of the sternum to ensure accuracy.
4. A nurse is caring for a patient on contact precautions due to a Clostridium difficile
infection. What is the priority intervention?
A. Use an alcohol-based hand sanitizer before exiting the room.
, B. Wear an N95 respirator at all times.
C. Ensure the patient is in a room with negative pressure airflow.
D. Wash hands with soap and water after providing care.
Answer: D
Rationale: C. difficile is a spore-forming bacterium that is resistant to the alcohol found in
hand sanitizers. Mechanical friction and rinsing with soap and water are the only effective
ways to remove these spores from the skin. Contact precautions also require the use of
gloves and gowns, but handwashing is the specific priority for this pathogen.
5. Which phase of the nursing process involves the nurse gathering data about the patient’s
health status?
A. Assessment
B. Implementation
C. Planning
D. Evaluation
Answer: A
Rationale: The assessment phase is the first step of the nursing process and involves
collecting subjective and objective data. This phase is critical because all subsequent steps
depend on the accuracy of the information gathered. During assessment, the nurse utilizes
techniques such as interviewing, physical examination, and reviewing medical records.
224 Fundamentals - Skills | Chamberlain
1. When a patient’s hands are visibly soiled with blood or body fluids, which hand hygiene
method should the nurse use?
A. Washing with soap and water
B. Alcohol-based hand rub
C. Wiping with a dry paper towel
D. Rinsing with warm water only
Answer: A
Rationale: The CDC and WHO guidelines state that soap and water must be used when
hands are visibly soiled. Alcohol-based rubs are ineffective against physical debris and
certain spores like C. difficile. Proper technique requires at least 20 seconds of vigorous
scrubbing to mechanically remove microorganisms.
2. In which order should the nurse apply personal protective equipment (PPE) before entering
an isolation room?
A. Gown, Mask, Goggles, Gloves
B. Gloves, Gown, Mask, Goggles
C. Mask, Goggles, Gloves, Gown
,D. Goggles, Mask, Gown, Gloves
Answer: A
Rationale: The correct sequence for donning PPE is to start with the gown to protect
clothing, followed by the mask or respirator. Next, goggles or a face shield are applied to
protect the eyes and face. Finally, gloves are put on and pulled over the cuffs of the gown to
ensure complete coverage.
3. The nurse is preparing to take a patient’s blood pressure. Which action will result in an
incorrectly low blood pressure reading?
A. The arm is positioned above heart level
B. Cuff wrapped too loosely
C. Using a cuff that is too narrow
D. Deflating the cuff too slowly
Answer: A
Rationale: If the arm is positioned above the level of the heart, gravity helps blood flow
and results in a false low reading. Conversely, a cuff that is too narrow or wrapped too
loosely would typically cause a false high reading. Proper positioning requires the arm to
be supported at the midpoint of the sternum to ensure accuracy.
4. A nurse is caring for a patient on contact precautions due to a Clostridium difficile
infection. What is the priority intervention?
A. Use an alcohol-based hand sanitizer before exiting the room.
, B. Wear an N95 respirator at all times.
C. Ensure the patient is in a room with negative pressure airflow.
D. Wash hands with soap and water after providing care.
Answer: D
Rationale: C. difficile is a spore-forming bacterium that is resistant to the alcohol found in
hand sanitizers. Mechanical friction and rinsing with soap and water are the only effective
ways to remove these spores from the skin. Contact precautions also require the use of
gloves and gowns, but handwashing is the specific priority for this pathogen.
5. Which phase of the nursing process involves the nurse gathering data about the patient’s
health status?
A. Assessment
B. Implementation
C. Planning
D. Evaluation
Answer: A
Rationale: The assessment phase is the first step of the nursing process and involves
collecting subjective and objective data. This phase is critical because all subsequent steps
depend on the accuracy of the information gathered. During assessment, the nurse utilizes
techniques such as interviewing, physical examination, and reviewing medical records.
